CircleUp Education Training or Consulting Anti-Discrimination Participant Reporting Tool

Participant Anti-Discrimination Feedback Survey

Description

The Participant Anti-Discrimination Feedback Survey provides a structured and confidential method for training participants to report any experiences or observations of discrimination during CircleUp Education programs. The feedback collected through this survey enables CircleUp Education to address incidents promptly and effectively, ensuring a safe and inclusive learning environment for all participants.

Confidentiality Statement

All information provided in this survey will be kept strictly confidential and will only be used for the purpose of investigating and resolving the reported incident. Your privacy is of utmost importance to us, and we are committed to protecting your identity and personal information throughout the process.

Question Title

* 1. Date and time of Incident

Date / Time

Date

Time

AM/PM

Question Title

* 2. Person doing the discriminatory or biased action

A CircleUp Staff Member

A training participant

The discrimination or bias exist within the training content (Presentation, handout, tools)

Question Title

* 3. Type of Discrimintion - Check All That Apply

Verbal

Non-verbal

Written

Embedded within training content

Question Title

* 4. Nature of Incident - Please describe the nature of the discrimination (select all that apply):

Explicit Discrimination (overt and intentional actions or remarks)

Implicit Discrimination (subtle or unintentional biases/microaggressions)

Harassment

Exclusion from activities or discussions

Offensive language or jokes

Inappropriate visual materials

Other (please specify)

Question Title

* 5. Type of Discrimination Experienced or Observed - Please indicate the type(s) of discrimination involved in the incident (select all that apply):

Race

Color

Religion

Creed

Sex/Gender

Gender Identity/Expression

Sexual Orientation

National Origin

Immigration Status

Age

Disability

Marital Status

Veteran Status

Other (please specify)

Question Title

* 6. Description of the Incident - Please provide a detailed description of the incident, including what happened, how it occurred, and any relevant context.

Question Title

* 7. Please Upload any evidence that can help us in our investigation of this matter. (Photos, screen shots, etc)

Please upload any evidence or email it to executive.synergist@circleuped.org

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 8. Location of the Incident - Physical Location, Online Platform - please sepcify if it's Zoom Chat, Discussion Forum, or presentation.

Question Title

* 9. People involved. Please specify the people who witness or were involved in the action. If you do not feel comfortable doing so, please state that as well.

Question Title

* 10. Desired Outcome - What would you consider a satisfactory resolution to this incident? (e.g., apology, policy review, additional training for staff, etc.)

Question Title

* 11. OPTIONAL - Provide us with your contact information if we can reach out to you with further questions. Leave blank to remain confidential.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number